I gladly accepted the invitation to argue for transurethral
resection of the prostate (TURP) in the surgical treatment of benign
prostatic hyperplasia (BPH), although I am a young urologist with an
inherent bias towards technology and innovation. I am also capable of
performing a Holmium laser enucleation of the prostate (HoLEP).[sup.1]
Among the various minimally invasive surgical therapies (MIST), laser
therapies (for resection or vaporization of the prostate) seem to be the
most promising. Similar to robotic surgery,[sup.2] lasers also are
attractive to patients and surgeons. How much of this attention is hype
versus reality? Let us review the best available evidence from
randomized controlled trials (RCTs).

The merits of TURP

TURP to treat BPH has been the gold standard for decades. It is
still considered the standard by the CUA,[sup.3] and as the
"benchmark for surgical therapies" by the American Urological
Association.[sup.4] Moreover, the European Urological Association
considers TURP "the treatment of choice for prostates sized 30 to
80mL."[sup.5]

TURP has been demonstrated to be efficient, cost-effective and, most
importantly, durable with low long-term complications and re-treatment
rates.[sup.6]-[sup.9] The seminal multicentre randomized trial comparing
TURP with watchful waiting demonstrated a 52% reduction in treatment
failure in TURP, a 1% risk of urinary incontinence similar in the
watchful waiting group, and an overall decline in sexual function
identical to the watchful waiting group.[sup.7] More recently, Reich and
colleagues published a contemporary prospective evaluation of 10 654
patients who underwent TURP statewide.[sup.8] The mortality rate was
0.10% and the cumulative short-term morbidity rate was 11.1%; both rates
continuously declined compared to a previous classical study by Mobust
and colleagues of 3885 patients.[sup.6] Complications of TURP include
failure to void (4.5% to 5.8%), surgical revision (1.1% to 5.6%),
urinary tract infection (3.6% to 4.2%), bleeding which requires
transfusions (2.0% to 2.9%) and TUR syndrome (0.8% to 1.4%).[sup.8,10]

The wide acceptance of medical treatment has significantly decreased
the use of TURP in Canada[sup.11] and worldwide. In the United States,
the advent of a multitude of expensive office-based or outpatient MIST
has further contributed to the decrease of TURP, which represented 39%
of total BPH surgeries in 2005.[sup.12] TURP still comprises 95% of all
surgical procedures in Europe,[sup.5] and in countries with universal
health-care systems, such as Canada.

Bipolar TURP (B-TURP) is one of the most recent advances in TUR
surgery. B-TURP has an improved safety profile compared with monopolar
TURP (M-TURP). Mamoulakis and colleagues, in their detailed
meta-analysis of 16 RCTs (1406 patients), compared B-TURP and M-TURP.
They found that B-TURP, while maintaining comparable efficacy
(short-term data <12 months), resulted in a 2% decreased
risk of TUR syndrome and a 5% risk reduction of clot retention.
Furthermore, irrigation and catheterization duration were significantly
shorter with B-TURP, on average 8.75 hours and 21.77 hours,
respectively. Operation times, transfusion rates, retention rates after
catheter removal and urethral complications were not significantly
different.[sup.14] Another meta-analysis of data from 10 RCTs compared
B-TURP and M-TURP (890 patients).[sup.10] This study showed less
frequent complications and overall morbidity for B-TURP. None of the 10
trials mentioned TUR syndrome as an adverse event of B-TURP.
Perioperative complications (acute urinary retention, clot retention and
urinary tract infection) were significantly less common in B-TURP (12%
vs. 18%), as well as late complications (bladder neck stenosis, urethral
stricture, reintervention) (3.5% vs. 10.5%).[sup.10]

In summary, TURP and its modifications offer well-documented
long-term data of efficacy and safety in surgical treatment for BPH.
Emerging laser treatments that deserve consideration in this debate are
HoLEP and photoselective laser vaporization of the prostate (PVP).

HoLEP

There are 4 RCTs comparing HoLEP and TURP.[sup.15]-[sup.18] The mean
follow-up ranged from 1 to 3 years. HoLEP demonstrated equal efficacy
compared to TURP in short- and medium-term follow-up (International
Prostate Symptom Score [IPSS] and quality of life score [QOL], and
maximum flow rate [Qmax]) owing to similar resected adenoma
tissue-weights. However, HoLEP operating room times were significantly
longer in all trials by an average of 26 minutes, 27 minutes, 13
minutes, and 29 minutes, respectively;[sup.15]-[sup.18] it was almost
double the time of TURP in 1 trial.[sup.15] Catheter duration,
hospital-stay and blood loss were in favour of HoLEP.[sup.10,19] However
there were no differences in blood transfusions, urethral stricture,
stress urinary incontinence and reintervention rates in 1
meta-analysis.[sup.19] Urgency symptoms were more pronounced after HoLEP
compared to TURP in another meta-analysis (5.6 vs. 2.2%).[sup.10]
Bladder injury during morcellation and postponed morcellation due to
equipment failure are reported complications with HoLEP. Overall, there
were no significant differences in overall morbidity.[sup.10]

The learning curve with HoLEP is a big issue and a formidable
challenge, for some. We estimated the learning curve between 20 and 30
cases, after watching a priori an average of 20 cases, and being
proficient in TURP (another 20 to 30 cases).[sup.1] Shah and colleagues
described the learning curve of an experienced endourologist. A plateau
was reached only after 50 cases.[sup.20] Consider this for a moment: how
many residents in a particular program are we able to teach at this
rate? And how many practicing urologists are willing to dedicate enough
time and effort to learn HoLEP?

Cost is another issue. HoLEP requires a 100-W laser; I suspect most
hospitals have a lower power laser for stone surgery. There is also the
added cost of the fibres and morcellator.

Conceptually, HoLEP is a sound technique and offers significant
advantages for larger glands obviating the need for simple open
prostatectomy.[sup.21,22] But this is another debate; in my opinion
HoLEP is more advantageous for large glands compared to open
prostatectomy. HoLEP has been around for more than 13 years, but has not
been embraced by mainstream urology beyond a select group of urologists
worldwide.

Photoselective laser vaporization of the prostate

PVP uses 532-nm lasers (80-W potassium-titany-phospahte [KTP],
GreenLight, AMS, Minnetonka, MN) or 120-W lithium borate (LBO) to create
a TURP-like channel. It was initially proposed as an alternative to TURP
in anticoagulated patients. One inherent limitation of PVP is the
absence of tissue diagnosis.

There are 2 RCTs comparing PVP to TURP.[sup.23,24] Follow-up data is
very limited. Both studies showed an advantage for PVP in duration of
catheter and hospital stay. While the study by Bouchier-Hayes and
colleagues[sup.23] demonstrated non-significant differences in terms of
efficacy with a 12-month follow-up, Horsanti and colleagues showed that
measurements of efficacy (IPSS, Qmax and post-void residual) were all
significantly inferior in PVP, even with shorter follow-up.[sup.24]
Operating room times were also significantly longer for the PVP (87 vs.
51 minutes). Of note, transrectal ultrasound volumes were 70 to 100 mL
in this study.[sup.24] The percentage volume reduction was also
significantly lower in PVP group. Reoperation was necessary in 7 of 39
patients in PVP, but none in the TURP group. The authors concluded that
intraoperative and perioperative safety and early functional results of
TURP are superior to PVP in patients with prostates larger than 70
mL.[sup.24] A meta-analysis showed increased postoperative urinary tract
infections compared to M-TURP and B-TURP (12% vs. 4.1 vs. 2.6%), and
increased dysuria (8.5% vs. 0.8% vs. 0%, respectively).[sup.10]

Another RCT compared PVP and open prostatectomy in large glands
(average 93 vs. 96 mL). Operating room times were significantly longer
for PVP (80 vs. 50 minutes). At the 18-month follow-up, data showed
similar Qmax and IPSS scores, but inferior QOL scores. In addition, at 3
months, residual prostate volume was significantly lower in the open
prostatectomy group and remained as such throughout follow-up.[sup.25]

As opposed to HoLEP, the learning curve of PVP is felt to be
shorter.[sup.26] It is estimated around 5 cases in TURP-experienced
surgeons.[sup.27]

Cost is more of an issue with PVP. Lasers are sold at over $100K and
fibres are disposable. There are no other usages for this equipment,
unlike with the Holmium laser. Furthermore, this technology is
constantly changing and there are different lasers and powers on the
market quite frequently.

Gupta and colleagues concluded that lasers are superfluous in the
surgical management of BPH, particularly in developing countries. They
argue that their cost, unproven long-term durability, steep learning
curve and lack of advantages over TURP make them unreasonable for
BPH.[sup.28]

In summary, PVP efficacy data suffers from short follow-up. PVP is
significantly longer and seems to be less effective for larger prostates
as compared to TURP. The reoperation rates are also high.

Conclusion

TURP is still alive and well in 2010, despite Stamey's
affirmation in 1993 that "TURP is now a therapy of
history."[sup.29] TURP has taken on many challenges, but still
remains the gold standard to which others are compared.[sup.30]

TURP is adequate for its intended use; TURP outcomes depend on
surgeons' experience, the patient's gland size and
comorbidities. Therefore, in appropriately selected patients TURP has an
unsurpassed tract record of durability.

TURP is one of the basic endoscopic procedures that urology
residents learn and is also one of the bread-and-butter operations most
urologists perform. The equipment is available in virtually all
hospitals. On a personal note, in my practice I perform TURP for
"TURPable" prostates and HoLEP for larger prostates.